Proceedings of the Subcommittee on
Veterans Affairs
Issue 8 - Evidence - December 3, 2014
OTTAWA, Wednesday, December 3, 2014
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12:02 p.m. to study the medical, social and operational impacts of mental health issues affecting serving and retired members of the Canadian Armed Forces, including operational stress injuries (OSIs) such as post-traumatic stress disorder (PTSD).
Senator Carolyn Stewart Olsen (Deputy Chair) in the chair.
[English]
The Deputy Chair: Colleagues, we will commence this Subcommittee on Veterans Affairs. We're continuing our study on operational stress injuries of Canada's veterans, which includes post-traumatic stress disorder, or PTSD.
Our witness today is Dr. Jitender Sareen, Professor of Psychiatry at the University of Manitoba. He is appearing with us today, by video conference, from Winnipeg. The committee has invited Dr. Sareen to obtain his perspectives on issues pertaining to operational stress injuries and to discuss his work in that field. Can you hear me, Dr. Sareen?
Dr. Jitender Sareen, Professor of psychiatry, University of Manitoba, as an individual: Yes, senator.
The Deputy Chair: I've read through your qualifications, so I'm hoping you'll go through a bit of a list of those when you first start speaking with us because they're quite extensive. We're very grateful to have you.
I wonder if my colleagues would agree to introduce themselves. Can I just say, off the top: Senator Lang is with us today. He has a statement that he'd like to read. After the introduction, Senator Lang, go ahead with your statement.
Colleagues, on my right, please, introduce yourselves.
Senator Wallace: Senator John Wallace from New Brunswick.
Senator Beyak: Senator Lynn Beyak from Ontario.
Senator Lang: Senator Dan Lang, Yukon.
The Deputy Chair: I'm Carolyn Stewart Olsen, the deputy chair, filling in today. I'm from New Brunswick.
Senator Lang: I would like to take a minute at this committee to recognize a Yukon veteran of the Second World War, Mr. Alec Van Bibber, who passed away on November 26, at the age of 98. Mr. Van Bibber was one of Yukon's last surviving Aboriginal veterans, having served in the Canadian military during World War II. He was an active member of the Canadian Rangers from 1947 until his passing, and he was a founding member of the Assembly of First Nations Veterans Roundtable.
Mr. Van Bibber is a truly great Canadian and a great Yukoner. His service to our country as a Second World War Aboriginal veteran, a Canadian Ranger since 1947 until his passing last week, an educator and an Order of Canada recipient will not be forgotten. We, in the Yukon, are proud of him, and I wanted to take a few minutes to let all Canadians know of this wonderful ranger and veteran, about whom I will be making a statement later this afternoon in the chamber. Thank you.
The Deputy Chair: Thank you, Senator Lang.
Dr. Sareen, I understand you have an opening statement, and we would be happy to have you go ahead with that, please.
Dr. Sareen: Thank you. Good afternoon, everyone. I'd like to thank everyone for inviting me to be a witness to the committee. In my opening remarks, I'm going to provide an overview of the current knowledge around operational stress injuries and discuss my thoughts on future directions in this important area for Canada.
For the committee to understand the context of my comments, I'll tell you a little bit about my experience. I'm a psychiatrist at the University of Manitoba. I've worked in the field of anxiety disorders, taught and conducted research for a number of years in the area of military personnel and veterans' health, as well as in First Nations suicide work.
I've worked at the Veterans Affairs Operational Stress Injury Clinic for the last five years, in Winnipeg, and so I'm going to move towards describing what operational stress injuries are. I think all of you are aware, but just to remind you, an OSI is any persistent psychological difficulty resulting from an operational duty performed while serving in the Canadian Armed Forces or as a member of the Royal Canadian Mounted Police. It is used to describe a broad range of emotional problems, including anxiety, depression or post-traumatic stress disorder, that interfere with a person's life.
How common are operational stress injuries? Our research group for the last 10 years has discovered, and others have also shown, that approximately one in four military veterans have had, at any time in the past year, a mental health problem. A portion of those are related to their operational duty, but not all of them.
Deployments where service members face high levels of threat, such as Afghanistan and Rwanda, have been shown to be an important risk factor for OSIs, compared to other missions where there's lower threat. When I sit with patients and families telling me the story of why they're presenting for mental health care, they describe a number of important stressors, not only the operational stress injury but also other issues: financial stress, childhood adversity, a family history of mental health problems, sometimes illicit drug use and, of course, chronic pain and physical health issues.
When we look at our Canadian history, we've come a long way in recognizing OSIs and providing treatments. Strong investments in research and programs have led to evidence-based policies in partnership with the Canadian Forces, Veterans Affairs Canada and Statistics Canada.
Statistics Canada has conducted outstanding national mental health surveys that provide a clear cross-sectional picture of the mental health treatment needs of military personnel and veterans. Those surveys have found a high proportion of military personnel and veterans have mental health issues — approximately one in four.
In response to those findings in 2002, there has been a large increase in improving the mental health system for our veterans. There have been programs to increase awareness of mental health programs, post-deployment screening programs, peer support programs, the national network of operational stress injuries clinics, as well as suicide prevention policies.
In the last month, there have also been a number of announcements around funding to support families of veterans, as well as support for the Canadian Institute of Military & Veteran Health Research that would hope to increase research in this important area.
Together, the efforts are aiming to try to provide evidence-based treatments for people suffering with operational stress injuries. Furthermore, the military and veterans' clinics have invested in training staff, in providing the highest quality state of the art evidence-based treatment for PTSD, post-traumatic stress disorder, and depression. There are interdisciplinary teams involved that, when needed, treat family members affected by operational stress injuries.
I'm going to now move to the current challenges. I want the committee to be aware that these challenges are not just for our military and veterans, but for all Canadians as well. Although the majority of people with mood and anxiety disorders respond to psychological and medication treatments, approximately 50 to 60 per cent, an important minority, continue to suffer. We need more research and evaluation in developing best practices, in helping people who don't respond to the first-line psychological treatment or the first-line medication treatment.
There's strong evidence that co-occurrence of alcohol and drug addictions worsen outcomes for people with mood and anxiety disorders. Self-medication with alcohol or marijuana, or other illicit drug-use is often used to cope with insomnia, nightmares and flashbacks. In my opinion, we need to invest in assessment and treatment of addictions among military personnel and veterans. I think we're doing a good job, but I think we can do a better job of helping the person who has both an addiction and a mental health problem.
Physical health problems and chronic pain are also common among military members and veterans, and the use and possible use of prescription opiate medications is an increasing concern. Also, the use of medical marijuana in the treatment of pain and post-traumatic stress disorder is highly controversial and hotly debated. We need careful research to determine best practices in treating patients with post-traumatic stress and chronic pain.
Another common and difficult to manage co-occurring issue is the presence of a personality disorder, such as borderline personality disorder, narcissistic personality or anti-social personality. These personality disorders are often life-long patterns, and problems in interpersonal relationships and are often associated with a high risk of suicide, disability and violence.
In civilian samples, novel psychological treatments, such as dialectical behaviour therapy, day programs that work on self-esteem, anger management and problem solving, have been shown to reduce self-harm behaviour and improve outcomes of people suffering with personality disorders. Our military and veterans mental health system could improve their capacity in assessing and treating people, who have an OSI and a co-occurring personality difficulty.
What can be done at a population level to reduce mental health problems and suicidal behaviour among members of the military and veterans? First we need to continue to raise awareness and reduce stigma among military personnel and veterans on the importance of early treatment of mental health problems and addictions. If you imagine someone with diabetes, who has had untreated diabetes for five to ten years, then what would be the impact of that on the body and on the person? It would be substantial. If we can improve earlier access to treatment for people with anxiety and depression, we might be able to reduce negative outcomes.
In the media, we need to tell positive stories of recovery and resilience to reduce the stigma associated with mental health service use. We need to consider psychological training and support at the time of entry in the military, and more importantly at the time when they leave the military. That period, in the one to two years after the service member leaves the military, is a highly vulnerable period and we need to improve services. The recent funding will hopefully have an impact on that.
Finally, limiting access to large quantities of prescription medications and firearms among people who are at high-risk for death or suicide is important. We need to think about policies and practices to reduce access.
In summary, there has been a rapid advancement in improving access to mental health services for people with OSIs. You think about 10 years ago to now, there's much more access. We could still improve our programs for people who have the co-occurring addictions and the physical health issues. Thank you for listening. I look forward to your thoughtful comments and questions.
The Deputy Chair: Thank you, Dr. Sareen. Our first questioner is Senator Grant Mitchell from Alberta.
Senator Mitchell: Thanks very much, doctor. That was very helpful and very impressive. There are clearly different reasons for occupational stress injuries or PTSD. In the military, it's often because of the stress of combat. For example, in the RCMP there have been documented cases, many, of PTSD from sexual harassment and harassment generally. Would the treatments that are effective on the one also be effective on the other? Is there crossover?
Dr. Sareen: Yes. Psychological treatment for post-traumatic stress disorder really works on a range of different types of trauma. It could be sexual trauma or sexual harassment. It could be a motor vehicle accident-related trauma. It could be the death of a soldier that the member has seen. So the psychological treatment is similar. The focus is on the particular trauma, depending on the person. If there's ongoing sexual harassment, then that becomes a different story. Then the person needs some advocacy around how to manage the environment.
Senator Mitchell: I'm quite taken by your point that there needs to be more research in this area, and of course resources are always limited to some extent. Given that there is crossover, so my first question was somewhat leading, and I got the answer that I wanted — thank you. I'm wondering whether there is something to be said for the unification of services, say, between the RCMP and the military and first responders. So those different groups of people from different organizations could go to centres that were centralized, as it were, rather than each of them having separate health care resources, which might not be able to share best practices and not be able to build to the thresholds that you need to do better research, and so on.
Dr. Sareen: I think that the operational stress injuries clinic that I work in, in Winnipeg, is similar to other cities. Members from RCMP, from Veterans or from the Canadian Armed Forces — all of them can have access to our clinic. You're absolutely correct. If you're trying to build best practices and excellence, you want to create those hubs across the country where people can access care. Training people to do the psychological interventions requires time and effort, and you need high-quality personnel who can do that. The clinics over the last 10 years have done a huge amount of service, where they've had national training. Where we could do a better job is probably around addictions and the co-occurrence of post-traumatic stress with addictions.
Senator Mitchell: I don't know whether you're aware of retired Lieutenant Colonel Stéphane Grenier. He was responsible for setting up a mentoring program in the Canadian Armed Forces. Studies showed that while all other treatments, say in the U.K. for their returning soldiers, were equivalent to ours, we in addition had this mentoring program. Studies showed the results were much better. He is now working in the public health care system on a similar thing. Are you aware of the significance of mentoring as a supplementary treatment? Do you utilize that or would you recommend it?
Dr. Sareen: Can you describe how the mentoring was done, because I'm not familiar with that?
Senator Mitchell: Maybe mentoring is the wrong word. Thank you. It would be more a kind of support. Each member of the military with a PTSD might be assigned a support colleague, who has it or doesn't have it, almost like the Alcoholics Anonymous model in a sense. You work with people who give you support. It's support rather than mentoring.
Dr. Sareen: The peer support model is very important and is part of the team. The person who is suffering with an OSI has the family around them and the peer support as well as the treatment providers. Having that team around the person is really important.
Senator Wallace: Dr. Sareen, in dealing with these types of psychological problems, I'm sure it's an oversimplification to say that veterans suffer from physical disabilities and psychological problems. As a layperson, it's easy to put them into one of the two categories, not thinking the extent to which they're interrelated. In treating operational stress injuries, perhaps the treatment of those injuries would be dependent upon the treatment and solving of the physical problem. If the physical problem can be removed, perhaps the psychological issues would disappear as well. Is there anything to that?
Dr. Sareen: Absolutely. Physical health issues often drive service use; so pain and PTSD are quite linked. Somebody who has had chronic pain related to an injury or concussion-related dizziness or headaches, there's quite a bit of literature showing that those two interact. Rather than saying, ''Go get your physical health problem treated and then we'll see you for the psychological treatment,'' or the other way around, we need to have parallel treatment. We need to bring down both the physical pain and physical health issues as well as help the psychological problem. It's usually complex.
When we see people with ongoing difficulties, they often have physical health issues; they have emotional issues; sometimes they have addictions; and they have financial stress, as well as relationship problems in their family. All of those things start to come together. In our clinics we try to work on one thing at a time to try to understand the person's view of their physical health issues and other stressors to try to problem solve around each of those.
The challenge, not just in military and veterans' health but in Canada, is that access to medications is much easier than psychological treatment. You can go to your family doctor and get a prescription for something that helps. But we find that people have not had a lot of good supportive and evidence-based psychological treatment in the general public system. Our clinics and veterans' clinics are better because we've had a lot of support. It's a combination of both physical health issues and psychological. What does it mean to the person to have the pain? What does it mean about their future? Often there's catastrophization that things will never get better and that leads to a cycle of more pain.
Senator Wallace: My father was in the Second World War and although he talked little about it, in more recent years we've heard about some of what he went through. Many of us have parents and grandparents who served in the wars. The types of services and psychological treatments we're talking about today weren't available to them. The disorders weren't recognized yet people carried on. People managed to have very successful and productive lives, but I'm sure some didn't.
How has that been able to occur? It makes me think that if people do not receive professional treatment for these operational stress injuries, from your research, does there seem to be an ability for people, through support of their family over time, to effectively find solutions for themselves, or does it always require professional treatment?
Dr. Sareen: Excellent question. We have done some work in the general population. Civilians have those, but we haven't had the data in our military and veterans on this exact question. We've been trying to understand that. One of the studies we want to do is to take the 2002 mental health survey and look at people over 12-15 years and follow up to see how many had a natural recovery without any treatment.
In civilian samples, we found that about 50 per cent of people will have recovery without any psychological treatment or psychiatric treatment. Their functioning might be a little bit lower, as you're describing, but not as bad as it was. In terms of the idea that people recover with family support, a portion of them do. Not everybody needs to get treatment. However, we showed in our general population that if you had co-morbidity — more than one condition, such as depression, anxiety, alcohol problems and childhood adversity — you were more likely to have persistence over a three-to five-year period than if you didn't. Again, this is an important piece: We're good at treating somebody with post-traumatic stress disorder or depression, but what is the best practice in treating someone with PTSD, alcohol problems and chronic pain? That's where we need research to say what the best strategy is because the antidepressant trials are done in the person who has no co-morbidity, they have one disorder. It's not really clear what is useful.
If you look at other areas in medicine, like cancer and AIDS, the investment in research to look at trying to improve outcomes has made huge gains. If we can think about investing in research and programs to understand what to do when the first line treatment doesn't work and the person is coming and still struggling, that's where we need to go in the next number of years.
Senator Wallace: Thank you, doctor.
In comparing the strategies we use in Canada to address operational stress injuries, do they differ in any significant way from, for example, strategies used with veterans in the United States and the strategies employed by the governments in the United States?
Dr. Sareen: That's a good question. The U.S. veterans system is much larger than our Canadian one. There has been a lot of collaboration between our Canadian policy-makers and treatment providers in the U.S. I'm not familiar with the pension assessments and how veterans are assessed to be deemed to have an operational stress injury or are eligible for benefits. I don't know enough about the similarities and differences between Canada and other countries. As you know, that's one of the major stressors for our veterans and their families. The military is taking care of a number of things during the service. What happens after? It would be helpful to know what the other policies are but, I'm sorry, I don't know.
Senator Beyak: Thank you for an excellent presentation. I agreed with what you said about needing more positive media stories on the successes and outcomes that are working. I had a soldier sit beside me on a plane in March last year and he said he's a victor, not a victim. He learned that from the psychological training he had. Can you tell me if the University of Manitoba has those kinds of strategies, or if your clinic does, which you can share for our recommendations to get that positive message out?
Dr. Sareen: The whole issue of media and suicide is quite controversial. Almost every suicide prevention policy around the world says that media reports of suicide are sensationalized, where it's front page and the story is told over and over again, and there is a contagion effect that could happen. We've tried to work with the Canadian Psychiatric Association to provide that information to the media. The media is trying to bring knowledge about suicide into the public forum and to change policies and increase awareness. But we're trying to work with the Canadian Psychiatric Association and the military to look at working together with the media to say: We're all on the same team. We're trying to reduce suicides, but how do we do that?
You need to know that when you tell a story about someone who has died from suicide, within that story you need to provide options of crisis resources and positive outcomes as well. The challenge is that some media feel we're trying to censor them, and that's not the idea. It's trying to have safe reporting. If you can help us get that message across, it would be great, but over time we're trying to work with the media on that. More stories about victors rather than victims is an important way.
Senator Beyak: I commend you for that.
I have a supplementary question. Do you know if the incidences of suicide in the Armed Forces have actually increased or if we're just more aware because of the media, as you said, repeating them over and over, or if there have been spikes in the past, as Senator Wallace said, after the Second World War, after any of the combat issues we've been engaged in? Do you know?
Dr. Sareen: To our knowledge, there has not been an increase in military suicides during military service. There has possibly been some increase in veterans' suicides. Again, our Canadian military is a much smaller service than the U.S. In the U.S., military suicides have gone up exponentially in the last number of years. There are different reasons for that. One is that they have had very long deployments, where they're deployed for over a year. So there is no increase in military in Canada that we're aware of; a slight increase in the number of veterans. I think that vulnerable period during the first two years is important.
Senator Beyak: Thank you very much for your research. It's excellent.
The Deputy Chair: Before the second round, I will ask a couple of questions myself.
I heard a statistic that I'm not sure about; I just want clarification. Is it one in four people serving in the military are more prone to getting an OSI? Is that what you said?
Dr. Sareen: One in four, in any one year, meet the criteria for a mental health problem, but you have to remember that mental health problems are common and are not necessarily all related to an OSI or a deployment-related issue. So we've tried to disentangle that, and it's difficult. Probably about a quarter of those 25 per cent — a quarter of a quarter — have an OSI-related mental problem at any one time. With the studies we did 10 years ago, we looked cross-sectionally and said if you have to meet the criteria for depression and anxiety and you took all the soldiers who are active in the military, a quarter would meet criteria for any mental health problem.
The Deputy Chair: Is there any study done on the reason why that might be? Is it because it's a totally different life when you first enter the military, so problems are exacerbated because it's so different? Have you done anything on that, evidence-based?
Dr. Sareen: The rates of mental health problems in general are similar in the military and civilians. About one in four civilians will have a mental health problem, and one in four military personnel. There's a slight increase in depression in the military compared to the civilian population, and that's been shown repeatedly. But mental health problems are common and the causes are childhood adversity, recent life stressors. Those are everywhere. We've shown that a small proportion can be directly attributable to deployment, combat missions. We are currently looking at this in the recent surveys that have been done, so the studies on that will just be coming out.
Senator Mitchell: This is really interesting for us, Dr. Sareen. I would like to go back to the point made about the possible difference between World War II veterans and current-day veterans. My father was in the Second World War as well. 50,000 Canadians were killed. Almost every family had somebody who went over, an uncle, a brother, a father, a spouse, and so it permeated our culture so much more. One of the things we're noting today is that when veterans become veterans, they leave the force, they have trouble finding a job because they're not understood. The language that they use, the way they conduct themselves, isn't understood. Efforts are being made to make a transition and help in that regard. But could it be that there is a different cultural reaction in a sense or a lack of understanding of veterans today because it doesn't permeate our culture in the way that it did in 1945?
Dr. Sareen: Absolutely. I think that is a really important issue. If you look at the Vietnam vets, the homecoming was quite a challenge. I think at the recent Canadian Institute for Military and Veteran Health Research conference there was some work presented saying that respect for the military in our Canadian population is very high at this time. When the person retires from service with an operational stress injury, what are they going to do? How are they going to live their life? What's their identity? That seems to be a major issue.
Culturally as well, people may not be as aware of the challenges. I see a select group of people who are struggling with depression and anxiety. I don't know how easy it is for veterans to readjust when they don't have an OSI.
Senator Mitchell: One of the issues — and I think you mentioned it as an issue — is stigma and the problem that we find in organizations where somebody may know they have a problem but they're afraid to say so because it might limit their career. If a soldier is shot in the arm, one day the doctor can say that arm is perfectly okay now so there is no lingering effect and you can go back and become a general. Is there ever any time at which one can say definitively somebody is past PTSD, so at least to, in some official, formal, powerful way, absolve some of the PTSD victims of any chance of that stigma, where you could actually make it stick: this person is healthy and they can come back and be perfectly functioning, or is this the kind of disease that isn't that clear-cut ever?
Dr. Sareen: A substantial proportion, probably 50 to 60 per cent, recover and don't meet criteria for PTSD anymore over time. As the senator was saying before, a number of them recover without treatment.
When there are co-occurring difficulties of other problems, then there seems to be a higher likelihood of persistence. The rule in psychiatry that I was taught as a medical student was the one third, one third, one third. One third get a lot better. A third have a moderate recovery; they still have symptoms, but they're able to function well. A third continue to struggle over a long period of time.
Our clinics are very good at trying to assess that. It also depends on the job and the stressor, whether that person is able to go back to that particular duty. We have RCMP members who have seen a lot of atrocities and lots of difficult things, pulling down victims of suicide and that accumulation of trauma. If they've been off work for a long period of time, we usually do graduated return to work and try to gently increase rather than going back to full force.
Senator Mitchell: You mentioned the need for more research. I wonder if you could give me some idea — you're a doctor, I know, but you're also with a university institution. Where do you get funding for research? If we were to increase it or restructure it, where would be the best sources of funding? Would it be from Veterans Affairs? Would it be from national research funding agencies? Would it be through universities? How would you structure that funding?
Dr. Sareen: Can ''all of the above'' be an answer?
Senator Mitchell: Sure, that's a great answer.
Dr. Sareen: The Canadian Institute for Military and Veteran Health Research Forum is a really fantastic organization because in the last five years they've created 35 institutions coming together, and military and veterans coming together. The idea with research is to have minimal bias. The challenge is, if military and veterans do the research, then there's bias to make sure that the programs are being done. There could be negative media attention. It's important to have that arm's-length process. The CIMVHR and the national research agencies like the Canadian Institutes of Health Research are trying to have that independence and minimal bias research.
Scientists are trying to understand the truth. If you think about smoking 40 years ago, everybody smoked and nobody knew it was related to cancer and companies made a lot of money. If we're trying to have rapid advancement in understanding who is going to do well in a deployment, who is going to suffer, how can we improve access to treatments, we need to look at what's been done in cancer care, in heart disease. You really have to invest a lot to change trajectories of illness.
Senator Wallace: Dr. Sareen, in your opening comments, in your words you said that we've come a long way in providing more effective treatment for our veterans suffering from operational stress injuries. I know there are undoubtedly many reasons for that, but I'm wondering if there are one or two key, or what you would view as the most significant changes that have occurred over this 10-year period that have resulted in this improved treatment.
Dr. Sareen: The first thing was the 2002 national mental health survey that was done of 8,000 service members to actually have an understanding of what are the needs of our Canadian military. That survey is still around the world the best survey that's been done, and that's because Statistics Canada does fantastic surveys. That level of trying to understand what is the need started it all.
The second major issue has been the Veterans Affairs Operational Stress Injury Clinics that have been pushed across Canada, as well as the Canadian Forces clinics. Within those clinics, there's been a very strong effort in training staff to do psychological treatment for post-traumatic stress and depression.
As I mentioned before, access to medications is easy but over time most of the mental health problems require cognitive behaviour therapy or evidence-based treatment. Our clinics have trained to the highest level. So veterans get very high-quality access to psychological treatment that I don't think our civilian system has the same access to.
Senator Wallace: It's reassuring to hear that. Thank you.
The Deputy Chair: If I may, doctor, I'm a strong supporter of the service dogs for PTSD sufferers. I take veterans with their dogs to schools and speak to children about PTSD. I feel that anyone can get this, and that's my message to the children: You can get this, but it can be dealt with. I am concerned that within the military, once a veteran says they need the service dog, the military then says, ''You can't work anymore. You can't go back to your job anymore.'' I would suggest that that might be just the opposite, that this is one method of treatment.
I'd like to hear your views. I think Senator Wallace spoke briefly on this, and I think all of us are wondering: How can it be recognized that there is this syndrome, but it is also something you can learn to deal and cope with and carry on a normal life?
Dr. Sareen: There has been a lot of interest in service dogs in post-traumatic stress, as well as in epilepsy. I'm supportive of our patients who are interested in doing that, and if they find it helpful. There hasn't been a lot of careful evaluation to say, ''Yes, this is an important treatment.'' I think that needs to be done. Those are examples of programs that need to be evaluated so that we can have evidence-based policies.
Again, people have access to medications, but there's a lot of emphasis now within mental health on exercise, that exercise is an important way of reducing depression and anxiety. It helps with how we work together with our clients to get that service.
The Deputy Chair: I don't think PTSD is necessarily a totally debilitating disease that you will never overcome. I think that message is very important to a lot of people who have PTSD. Would you agree with that?
Dr. Sareen: I absolutely agree with you. As I described before, the rules my mentor taught me in medical school are that two thirds of people will have quite a bit of moderate recovery — one third will be symptom-free, a third will have moderate recovery and they can function. Most of our treatments are trying to help the person function as best as possible. We try to figure out what's going to help them. If they can't leave the house without a dog for weeks, that's step one. We start to work with them where they are and help them through that.
I agree with you about the importance of giving a positive message and trying to help our veterans see that this is something that's recoverable.
The Deputy Chair: Thank you very much. I don't see any more questioners on my list. I want to thank you so much for taking the time to share with us your methods of treatment and your message. I think it's been a great help to us in understanding the mechanics of PTSD and OSIs and some of the treatments that you've suggested. Thank you so much.
I declare this meeting adjourned.
(The committee adjourned.)